Background: Severely calcified coronary lesions remain challenging targets for percutaneous coronary intervention (PCI) and are associated with impaired outcomes. Several methods of calcium-modification are available but their application remains heterogenous. We aimed to (i) investigate the utilization of calcium-modification techniques during PCI, (ii) evaluate temporal trends and (iii) analyze patient characteristics in a large, nationwide German registry.

Methods: This was a retrospective analysis of healthcare records obtained from the German Federal Bureau of Statistics. Patients >18 years of age hospitalized for PCI were included. Diagnoses, comorbidities, and procedural aspects were assessed by ICD-10 and OPS codes. Calcium-modification was defined as the application of blade angioplasty (i.e. cutting/scoring balloons), rotational atherectomy, laser atherectomy, and intravascular lithotripsy (IVL).

Results: We analyzed 3,141,303 cases of patients undergoing PCI between 2010 and 2019 (mean age 68.49 ± 11.58 years; 28.4% female). Calcium-modification techniques were performed in 97,009 cases (3.1%). According to the hospital annual PCI volume, utilization was 2.0% (<500 cases), 3.1% (500 to 1,000 cases), 4.0% (1,000 to 1,500 cases), and 4.2% (>1,500 cases). The fraction of patients with acute coronary syndrome was lower in the calcium modification group compared with the standard PCI cohort (27.7% vs. 42.3%; p<0.001). Patients receiving calcium modification were older (71.56 ± 10.27 vs. 68.39 ± 11.61; p<0.001), less likely female (25.9% vs. 28.5%; p<0.001), and had a higher burden of comorbidities (e.g. diabetes mellitus: 36.2% vs. 29.2%; chronic kidney disease: 24.5% vs. 17.1%; peripheral artery disease: 10.1% vs. 5.9%; history of coronary artery bypass graft surgery: 10.5% vs. 5.9%; p<0.001 for all) compared with patients receiving standard PCI. Overall, the number of annual PCI procedures increased from 276,399 (2010) to 345,765 (2019). The rate of calcium-modification increased from 2.1% in 2010 to 5.0% in 2019 (Figure 1A). This temporal trend was triggered by an increase of blade angioplasty (1.6 to 3.5%), rotational atherectomy (0.4 to 1.5%) and the introduction of coronary of IVL in 2019 (0.2%) whilst laser atherectomy was limited to a minority of cases during the whole observation period (0.02%) (Figure 1B).